Effects of intraoperative low-dose esketamine on postoperative pain after vestibular schwannoma resection: A prospective randomized, double-blind, placebo-controlled study.

AIMS: Esketamine may reduce acute postoperative pain in several settings. However, the effects of low-dose esketamine on postoperative pain after vestibular schwannoma (VS) resection with propofol/remifentanil total intravenous anaesthesia (TIVA) are unclear. The aim of this study is to observe the effects of intraoperative low-dose esketamine on postoperative pain after vestibular schwannoma resection. METHODS: This single-centre, randomized, placebo-controlled, double-blind trial included 90 adults undergoing VS resection via the retrosigmoid approach with TIVA. The patients were randomly allocated to two groups: esketamine or control (n = 45 in each group). Patients received low-dose esketamine (0.2 mg/kg) or a similar volume of normal saline after dural closure. The primary outcome was the pain score during movement (gentle head movement) at 24 h postoperatively. Secondary outcomes included recovery time, bispectral index (BIS) values and haemodynamic profiles during the first 30 min after esketamine administration, and adverse effects. RESULTS: Low-dose esketamine did not reduce pain scores at rest (P > .05) or with movement (P > .05) within the first 24 h after surgery. Esketamine moderately increased BIS values for at least 30 min after administration (P < .0001) but did not affect heart rate (P = .992) or mean arterial blood pressure (P = .994). Esketamine prolonged extubation time (P = .042, 95% confidence interval: 0.08 to 4.42) and decreased the effect-site concentration of remifentanil at extubation (P = .001, 95% confidence interval: -0.53 to -0.15) but did not affect the time to resumption of spatial orientation. Postoperative nausea and vomiting rates did not differ between groups, and no hallucinations or excessive sedation was observed. CONCLUSION: Intraoperative low-dose esketamine did not significantly reduce acute pain after VS resection with propofol/remifentanil TIVA. However, BIS values increased for at least 30 min after esketamine administration.

Effect of Intraoperative Dexmedetomidine Use on Postoperative Delirium in the Elderly After Laryngectomy: A Randomized Controlled Clinical Trial.

Purpose: To examine whether intraoperative dexmedetomidine reduces postoperative delirium (POD) in elderly patients who underwent a laryngectomy. Methods: Patients were randomly assigned to receive dexmedetomidine or a saline placebo infused during surgery. The study period was July 2020 to January 2022. Participants were elderly individuals (≥65 years) who underwent a laryngectomy. Immediately after induction of anesthesia, a 0.5 µg.kg-1 bolus of study solution was administered for 10 min, followed by a maintenance infusion of 0.2 µg.kg-1.hr-1 until the end of surgery. Patients were assessed daily for POD (primary outcome). Plasma inflammatory factors were measured at baseline, on the first postoperative day, and on the third postoperative day. Results: In total, 304 male patients were randomized; 299 patients [median (interquartile range) age, 69.0 (67.0-73.0) years] completed in-hospital delirium assessments. There was no difference in the incidence of POD between the dexmedetomidine and control groups (21.3% [32 of 150] vs 24.2% [36 of 149], P=0.560). However, dexmedetomidine reduced POD in patients with laryngeal cancer and a higher tumor stage (21.6% vs 38.5%; OR, 0.441; 95% CI, 0.209-0.979; P=0.039). Dexmedetomidine reduced levels of C-reactive protein (CRP) (P=0.0056) and interleukin 6 (IL-6) (P<0.001) on the first and third postoperative days, respectively. More patients had intraoperative hypotension in the dexmedetomidine group (29.3% [44 of 150] vs 17.4% [26 of 149], P=0.015). Conclusion: Intraoperative dexmedetomidine administration did not prevent POD in patients with laryngeal cancer. Dexmedetomidine reduced serum CRP and IL-6 levels postoperatively but caused a higher occurrence of intraoperative hypotension in elderly patients after a laryngectomy.

Association between severe preoperative hearing impairment and postoperative emergence agitation among elderly patients undergoing middle ear surgery.

BACKGROUND: Hearing impairment is an established independent risk factor for delirium.Whether preoperative hearing impairment is associated with postoperative emergence agitation (POEA) in elderly patients remains unknown. This study aimed to investigate the association between preoperative hearing impairment and POEA in elderly patients undergoing ear surgery. METHODS: This prospective observational study was carried out at an otologic centre in a tertiary hospital between July 15, 2020, and February 28, 2021. Data of 417 elderly patients who underwent microscopic and endoscopic middle ear surgery were analyzed. Pure tone average was used to assess preoperative hearing function, with a PTA ≥ 50 dB indicating severe hearing impairment. POEA was measured using the Richmond Agitation-Sedation Scale. Multiple logistic regression was used to determine the association between preoperative hearing function and POEA. RESULTS: Of the 417 participants, 45.8% were men, and the median age was 64 (interquartile range: 62-67) years old. Severe preoperative hearing impairment was present in 113 patients (27.1%), and POEA occurred in 42 patients (10.1%). Multiple logistic regression analysis indicated that severe preoperative hearing impairment was associated with an increased risk of POEA (odds ratio: 2.031; 95% confidence interval: 1.044-3.954, P = 0.037). CONCLUSION: Pending confirmative studies, these findings suggest that severe preoperative hearing impairment could serve as an independent predictor of POEA in older patients undergoing middle ear surgery. These results highlight the need for further research to better understand the biomarker and pathogenesis of POEA, leading to identification of targeted interventions of POEA and improvement of postoperative outcomes in patients.

Factors Associated with Prolonged Extubation after Total Intravenous Anesthesia in Patients Undergoing Vestibular Schwannoma Resection.

OBJECTIVE: To identify factors associated with prolonged tracheal extubation after vestibular schwannoma resection in patients receiving propofol-remifentanil-based total intravenous anesthesia (TIVA). STUDY DESIGN: Single-center retrospective study of vestibular schwannoma resection performed by a single neurosurgeon between July 2018 and September 2021. SETTING: Tertiary academic medical center. PATIENTS: Adults receiving TIVA for vestibular schwannoma resection, classified according to extubation time: non-prolonged extubation (<15 min) and prolonged extubation (≥15 min). MAIN OUTCOME MEASURES: Time from end of surgery to extubation, demographic parameters, intraoperative variables, and familiarity between the anesthesia provider and the neurosurgeon were analyzed. Predictors for prolonged extubation were analyzed via multivariate analysis. The primary outcome was the incidence of prolonged extubation. The secondary outcome was factors associated with prolonged tracheal extubation. RESULTS: A total of 234 cases were analyzed. The median (interquartile range) extubation time was 9.4 minutes (7.2, 12.2 min). Extubation was prolonged in 39 patients (16.7%). Factors predicting prolonged extubation were significant blood loss (odds ratio [OR], 12.8; 95% confidence interval [CI], 2.6-61.7; p = 0.002), intraoperative neuromuscular blocking drug infusion (OR, 6.6; 95% CI, 2.8-15.7; p < 0.001), and lack of familiarity between the anesthesia provider and neurosurgeon (OR, 4.4; 95% CI, 1.5-12.3; p = 0.005). CONCLUSION: Significant blood loss, intraoperative neuromuscular blocking drug infusion, and lack of familiarity between anesthesia provider and neurosurgeon were associated with prolonged extubation following TIVA for vestibular schwannoma resection.

Preoperative Psychological Burdens in Patients with Vestibular Schwannoma.

OBJECTIVE: To assess preoperative psychological burden in patients with vestibular schwannoma (VS). METHODS: A total of 100 patients undergoing VS resection between September 2019 and June 2020 completed preoperative psychological screening. The Hospital Anxiety and Depression Scale (HADS) was applied the day before surgery, and a score >14 was considered clinically important. Univariate and multivariate logistic regression analyzes were used to identify risk factors associated with increased preoperative psychological stress. RESULTS: Of the 100 patients who underwent VS resection, 44% were male, with a mean age of 45.9 years. Twenty-two (22%) had HADS scores >14. For the univariate analysis, risk factors associated with elevated psychological burden included time since diagnosis, number of symptoms, headache, vertigo, and nausea and/or vomiting. In the regression analysis, the number of symptoms and greater time from diagnosis to treatment correlated with higher preoperative psychological stress. CONCLUSION: Nearly 1 in 4 patients with VS experienced clinically significant emotional burden preoperatively. Number of symptoms and greater time from diagnosis to treatment contributed to this psychological burden.

Postoperative Delirium is Not Associated with Long-Term Decline in Activities of Daily Living or Mortality After Laryngectomy.

PURPOSE: To determine the relationships between postoperative delirium (POD) and postoperative activities of daily living (ADL) and mortality in patients undergoing laryngectomy. We hypothesized that POD would reduce postoperative ADL and increase postoperative mortality. PATIENTS AND METHODS: The prospective study included older participants (age ≥65 y) undergoing total laryngectomy, partial laryngectomy, total laryngectomy plus neck dissection, or partial laryngectomy plus neck dissection under general anesthesia. The diagnosis of delirium was based on the Confusion Assessment Method algorithm, which was administered on postoperative days 1 through 6. ADL were evaluated using the Chinese version of the Index of ADL scale. Follow-up assessments of ADL and mortality were conducted 24 months after surgery. RESULTS: Of 127 participants (aged 70.3 ± 4.1 y), 19 (15.0%) developed POD. POD was not associated with a decrease in ADL after laryngectomy (p=0.599) nor with an increase in postoperative mortality [3/19 (15.8%) vs 12/108 (11.1%), p=0.560, Log rank test]. However, longer surgery duration was significantly associated with worse overall survival (OR, 3.262; 95% CI, 1.261-9.169, p=0.025). CONCLUSION: POD was not associated with long-term ADL or mortality after laryngectomy. Prolonged surgery was the only factor associated with a higher postoperative mortality rate.

Electromyographic Response of Facial Nerve Stimulation Under Partial Neuromuscular Blockade During Resection of Vestibular Schwannoma.

OBJECTIVE: To evaluate whether use of partial nondepolarizing neuromuscular blocking agents, at a train-of-four level 1, compromise facial nerve monitoring during vestibular schwannoma (VS) resection. METHODS: Sixty consecutive patients undergoing VS resection were enrolled into a partial peripheral neuromuscular blockade group or free of neuromuscular blockade group. Stimulation threshold to elicit an electromyographic response amplitude of at least 100 µV was recorded at the proximal and distal facial nerve after VS removal. The proximal-to-distal ratio of amplitude of the orbicularis oculi and oris muscles was calculated. RESULTS: All patients successfully passed the electromyography monitoring test. Mean electrical stimulation thresholds were higher in the peripheral neuromuscular blockade group than in the free of neuromuscular blockade group (0.12 mA vs. 0.06 mA at proximal site, P = 0.001; 0.08 mA vs. 0.03 mA at distal site, P = 0.0002). The differences in median proximal-to-distal amplitude ratios were not statistically significant in both groups. There was a trend toward more patients needing phenylephrine. Recovery profiles were comparable in the 2 groups. CONCLUSIONS: Although mean stimulation threshold to elicit a response amplitude was higher in the peripheral neuromuscular blockade group than in the free of neuromuscular blockade group at the proximal site, the stimulation thresholds in both groups were sufficient for facial nerve monitoring in VS surgery, indicating no clinical difference in both groups.

Risk Factors and Incidence of Postoperative Delirium in Patients Undergoing Laryngectomy.

OBJECTIVE: To explore the risk factors and incidence of postoperative delirium (POD) in patients undergoing laryngectomy for laryngeal cancer. STUDY DESIGN: Prospective cohort study. SETTING: Shanghai Eye, Ear, Nose, and Throat Hospital, Fudan University. SUBJECTS AND METHODS: A total of 323 patients underwent laryngectomy from April 4, 2018, to December 28, 2018. Perioperative data were collected. The primary outcome was the presence of POD as defined by the Confusion Assessment Method diagnostic algorithm. Univariate and multivariable logistic regression analyses were used to identify risk factors associated with POD. RESULTS: Of the patients who underwent laryngectomy during the study period, 99.1% were male, with a mean age of 60.0 years. Of these patients, 28 developed POD, with most episodes (88.1%) occurring during the first 3 postoperative days. The type of POD was hyperactive in 7 cases and hypoactive in 21 cases. The mean duration of POD was 1 day. The mean Delirium Rating Scale-Revised-98 score (a measure of POD severity) was 11.5. For the multivariable analysis, risk factors associated with POD included advanced cancer stage, lower educational level, higher American Society of Anesthesiologists classification, and intraoperative hypotension lasting at least 30 minutes. Intraoperative dexmedetomidine use was protective against POD. CONCLUSION: This study identified risk factors associated with POD, providing a target population for quality improvement initiatives. Furthermore, intraoperative dexmedetomidine use can reduce POD.

The effect of etomidate or propofol on brainstem function during anesthesia induction: a bispectral index-guided study.

PURPOSE: To compare the effect of etomidate versus propofol infusion on hemodynamic profiles, spontaneous breathing, and corneal reflex during the induction of anesthesia. METHODS: Adult patients (n=80) were randomized to receive etomidate (Group E, n=40) or propofol (Group P, n=40) infusion during anesthesia induction. Throughout induction, mean blood pressure and heart rate were monitored. Time to loss of consciousness (LOC), bispectral index (BIS), existence of spontaneous breathing, and corneal reflex at LOC were recorded. RESULTS: Fewer changes in hemodynamic profile occurred in Group E compared with Group P during induction of anesthesia. The mean time to LOC was shorter with etomidate than propofol (129.5 s vs 189.5 s, P<0.0001). BIS was lower in Group E compared with Group P at LOC (46.3 vs 52.9, P=0.0141). More patients exhibited spontaneous breathing in Group E compared with Group P at LOC (80% vs 17.5%, P<0.0001). Similarly, more patients maintained corneal reflex in Group E compared with Group P (34 patients vs 4 patients, P<0.0001). The incidence of etomidate-induced myoclonus was 17.5%. CONCLUSION: Compared with propofol infusion, etomidate infusion during anesthesia induction had fewer effects on the hemodynamic profile of patients. Among patients who received etomidate, the BIS value was lower at LOC, and more patients displayed spontaneous breathing and corneal reflex. TRIAL REGISTRY NUMBER: China Clinical Research Information Service, ChiCTR-IOR-17011050.

Quality of recovery in patients undergoing endoscopic sinus surgery after general anesthesia: total intravenous anesthesia vs desflurane anesthesia.

BACKGROUND: For sinus surgery, some centers favor total intravenous anesthesia (TIVA) over inhalation anesthesia. However, whether TIVA affects the patient's perceived quality of recovery remains unclear. This study used the Quality of Recovery-40 questionnaire (QoR-40) to compare patient recovery between surgical patients who received TIVA and those who received desflurane (DES) anesthesia. METHODS: Eighty patients (20 to 65 years old) undergoing endoscopic sinus surgery were prospectively enrolled and randomized to either the TIVA (propofol and remifentanil infusion) or DES (desflurane inhalation and remifentanil infusion) group. The QoR-40 was administered before surgery, at 6 hours after surgery, and on postoperative day 1 (POD1). Incidence of nausea and vomiting, remifentanil consumption, blood loss, and pain treatment were recorded. The influence of lesion extent (indexed as Lund-Mackay [LM] score) on recovery quality was also assessed. RESULTS: Forty patients were randomized into the TIVA group, and 40 patients were randomized into the DES group. The QoR-40 score at 6 hours after surgery was significantly higher in the TIVA group compared with the DES group (188.2 vs 182.6, respectively; p = 0.049), indicating a better quality of recovery in the TIVA group. TIVA resulted in less blood loss (p < 0.0001). A high LM score (≥12) was associated with lower QoR-40 scores at 6 hours after surgery (180.2 vs 187.2, p = 0.028) and on POD1 (181.5 vs 190.3, p = 0.003). CONCLUSION: This study shows that the quality of recovery for endoscopic sinus surgery patients was better with TIVA than with desflurane anesthesia. A high LM score was related to poorer recovery quality.

Sevoflurane anesthesia during pregnancy in mice induces hearing impairment in the offspring.

INTRODUCTION: Exposure to gamma-aminobutyric acid-mimetics and N-methyl-D-aspartate-receptor antagonists during pregnancy may lead to hearing loss and long-term behavioral abnormalities in the offspring. The purpose of this study was to explore the association between prenatal exposure to sevoflurane (SEV) anesthesia and hearing impairment in mice. MATERIALS AND METHODS: On gestational day 15, pregnant Kunming mice were exposed for 2 hours to 2.5% SEV plus 100% oxygen (anesthesia group) or 100% oxygen alone (control group). RESULTS: During auditory brainstem response testing on P30, offspring of the anesthesia group mice exhibited higher hearing thresholds at 8, 16, 24, and 32 kHz; longer peak latency of wave II at all four frequencies; and longer interpeak latencies from waves II to V at 16, 24, and 32 kHz, compared to the control offspring. Caspase-3, iNOS, and COX-2 activation occurred in the fetal cochlea of the anesthesia group. Mitochondrial swelling was observed in the anesthesia group offspring at P1 and P15. CONCLUSION: Our results suggest that SEV exposure during pregnancy may cause detrimental effects on the developing auditory system.

Dexmedetomidine in combination with sufentanil for postoperative analgesia after partial laryngectomy.

BACKGROUND: Dexmedetomidine as an adjunct with opioids has been confirmed to spare opioids usage and improve analgesia for postoperative pain treatment. Furthermore, dexmedetomidine can attenuate the airway reflex. The aim of this study is to assess the safety and efficacy of dexmedetomidine combined with sufentanil for postoperative analgesia after partial laryngectomy. METHODS: A total of 60 adult male patients were recruited and randomly allocated to receive sufentanil 1.0 µg ml-1 (Group S) or sufentanil 1.0 µg ml-1 plus dexmedetomidine 4 µg ml-1 (Group SD) for postoperative analgesia. The IV patient controlled analgesia (PCA) device was programmed to deliver 1.5 ml per demand with a 10 min lockout interval and 1.5 ml per hour background infusion. Cumulative consumption of sufentanil and pain intensity during 24 hour (h) after surgery were recorded. Coughing episodes per day, sleep quality, hemodynamic and respiratory profiles were measured. RESULTS: Compared with Group S, patients in Group SD required less sufentanil during the 0-24 h postoperative period (p < 0.0001) and reported significant lower pain intensity from the second postoperative hour to the end of the study (P < 0.0001). Daily coughing episodes, sleep disturbance was lower and patients' satisfaction was higher in Group SD (P < 0.05). Decrease in heart rate and mean blood pressure from baseline at 1 h, 2 h, 3 h, 12 h, and 24 h after operation were significantly greater in Group SD (P = 0.00). The incidence of PCA related adverse events were comparable between the two groups. CONCLUSION: Dexmedetomidine/sufentanil combination for postoperatjve analgesia in partial laryngectomized patients resulted in significant sufentanil sparing, better analgesia, reduced frequency coughing episodes, and better sleep quality. TRIAL REGISTRATION: Chinese Clinical Registry (ChiCTR): ChiCTR-TRC-14004618 , date of registration: 08 May 2014.

Environmental Enrichment Attenuated Sevoflurane-Induced Neurotoxicity through the PPAR-γ Signaling Pathway.

Sevoflurane is the most widely used inhaled anesthetic. Environmental enrichment (EE) can reverse sevoflurane-induced learning and memory impairment in young mice. However, the mechanism by which EE elicits this effect is unclear. The peroxisome proliferator-activated receptor (PPAR) regulatory pathway plays a critical role in the regulation of inflammation in central nervous system diseases. In this study, we investigated whether EE attenuates sevoflurane-induced learning and memory disability via the PPAR signaling pathway. Six-day-old mice were treated with 3% sevoflurane for 2 hours daily from postnatal day 6 (P6) to P8. Then, the mice were treated with EE. The effects of sevoflurane on learning and memory function, PPAR-γ expression in the brain, and the numbers of terminal deoxynucleotidyl transferase dUTP nick end labeling-positive cells and 5-bromodeoxyuridine-positive cells in the hippocampus were determined. Sevoflurane induced neuronal apoptosis and neurogenesis inhibition, which may impair learning and memory in young mice. Furthermore, sevoflurane downregulated PPAR-γ expression. Both EE and the PPAR-γ agonist, rosiglitazone, attenuated sevoflurane-induced neuronal apoptosis, neurogenesis inhibition, and learning and memory impairment. Our findings suggest that EE ameliorated sevoflurane-induced neurotoxicity and learning and memory impairment through the PPAR-γ signaling pathway. PPAR-γ may be a potential therapeutic target for preventing or treating sevoflurane-induced neurotoxicity.

Efficacy and safety of spontaneous ventilation technique using dexmedetomidine for rigid bronchoscopic airway foreign body removal in children.

BACKGROUND: In children, removal of an airway foreign body is usually performed by rigid bronchoscopy under general anesthesia. Debate continues regarding the respiratory mode (spontaneous or controlled ventilation) and appropriate anesthetic drugs. Dexmedetomidine has several desirable pharmacologic properties and appears to be a useful agent for airway surgeries. OBJECTIVES: This study evaluates the efficacy of spontaneous ventilation (SV) technique using dexmedetomidine for bronchoscopic removal of foreign bodies in children. METHODS: Eighty pediatric patients undergoing rigid bronchoscopy for airway foreign body removal were randomly divided into two groups. In the SV group, dexmedetomidine (4 µg∙kg(-1)) and topical lidocaine (3-5 mg∙kg(-1)) were administered and the patients were breathing spontaneously throughout the procedure. In the manual jet ventilation (MJV) group, anesthesia was induced with fentanyl (2 µg∙kg(-1)), propofol (3-5 mg∙kg(-1)), and succinylcholine (1 mg∙kg(-1)), and MJV was performed. RESULTS: The success rates of foreign body removal, the incidence of body movement and other perioperative adverse events, and hemodynamic changes were similar between the two groups. The SV patients required longer stays in the postanesthesia care unit (P < 0.01) but experienced less coughing (P = 0.029) in the recovery room. CONCLUSION: Dexmedetomidine may provide appropriately deep anesthesia and ideal conditions for rigid bronchoscopic airway foreign body removal without respiratory depression or hemodynamic instability.

Prognostic study of sevoflurane-based general anesthesia on cognitive function in children.

PURPOSE: It is unclear whether volatile general anesthetics have sustained adverse effects on the immature brains of children. We performed a self-controlled study to evaluate the effects of strabismus surgery under sevoflurane-based general anesthesia on the cognitive function of pediatric patients. METHODS: The study included 100 children of ages 4 to 7 years old scheduled to undergo strabismus correction under sevoflurane-based general anesthesia. Cognitive function was tested 1 day before the operation (T1), 1 month after the operation (T2), and 6 months after the operation by the Wechsler Preschool and Primary Scale of Intelligence (WPPSI) (Third Edition) method, which consists of 150 items. The scores at T1 were compared with scores at T2 and T3. RESULTS: Seventy-two children completed the three tests. At T1, they were 66.1 ± 7.7 months old and had a mean body weight of 21.6 ± 4.0 kg. The mean anesthesia time was 67.3 ± 9.8 min. The mean interval between T1 and T2 was 25.4 ± 6.8 days, and that between T1 and T3 was 182.1 ± 27.7 days. No statistically significant decrease in WPPSI scores was observed between T1 and T2, or between T1 and T3. CONCLUSION: These findings from our self-controlled study show that sevoflurane-based general anesthesia does not have significantly adverse effects on the cognitive function of 4- to 7-year-old children at 1 month and 6 months after strabismus surgery. Additional studies with a larger sample size are needed.